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of us spotted that he had fainted; we all mistook the faint for the onset of smooth anaesthesia, and but for a warning cried out by the technician who was following the blood pressure on the recording apparatus the patient might well have died. In the boy's case outlined above, Dr. Tomlin (2 November, p. 288) somewhat surprisingly attributes the death to pulmonary oedema. I have pointed out3 that in cases of sudden collapse and death in the dental chair when fainting was the only rational explanation pulmonary oedema seems to be a constant necropsy finding. Indeed, Dr. Tomlin himself has reported this finding.6 The case was that of a woman aged 22 sitting up in the dental chair who lost consciousness and collapsed during the injection within the mouth of 1-5 ml of a standard local analgesic solution. She died and "the post-mortem revealed acute pulmonary oedean." Discussing the cause of this death, Dr. Tomlin makes no mention of the pulmonary oedema. He attributes the death either to acute sensitivity to the analgesic agent or to "a severe dysrhythmina or a 'faint'."-I am, etc., J. G. BOURNE

BRITISH MEDICAL JOURNAL

sandflies, or ticks and which are known to be responsible for disease in man (usually fever but sometimes more severe manifestations such as encephalitis) not only in tropical and subtropical regions but also in areas as close to Britain as the south of France, Italy, and Cyprus. Viruses of this type are also known to be active in Scandinavia, Austria, and Portugal. Details of these viruses are probably a matter for the specialist, but their existence should be recognized by all practitioners. Diagnosis in the cases of Lassa, dengue, and yellow fevers is dismissed rather cavalierly, as "confirmed by serum antibody studies." This is so, but the pertinent question is-where can these be done? To my knowledge there is no virus laboratory in the United Kingdom where a service is available for the routine diagnosis of arbovirus infections. Tlhis is a small but important lacuna and one which it would be relatively inexpensive to fill.-I am, etc., R. N. P. SUTrON King's College Hospital Medical School, London S.E.5

Salisbury, Wilts

1Bourne, J. G., Studies in Anaesthetics, p. 131.

London, Lloyd-Luke, 1967. 2 Bourne, J. G., Anaesthesia, 1970, 25, 473. 3 Bourne, J. G., Lancet, 1973, 1, 35. 4 Bourne, J. G., Lancet, 1957, 2, 499. 5 Bourne, J. G., Lancet, 1966, 1, 879. 6 Tomlin, P. J., Anaesthesia, 1974, 29, 551.

John Locke SIR,-I was interested to read Mrs. Hilda M. Stowell's letter (30 November, p. 530) about my article on John Locke (5 October, p. 34). I am sorry if one sentence in my article gave the impression that Locke was in exile for the whole period 1660-89. In fact there is nothing in the artiole to suggest that. Locke followed Shaftesbury into exile in 1683 (that is, during Charles II's reign), lay low to avoid association with those involved in Monmouth's rebellion, and returned with William III in 1688. My article refers to Locke's five years in the Netherlands, which nmakes it clear that he went there in 1683. If Mrs. Stowell cares to read my book on Locke' she will, I think, find little to quarrel with.-I am, etc., M. V. C. JEFFREYS Lyndhurst, Hants 1 Jeffreys, M. V. C., 7ohn Locke; Prophet of Common Sense. London, Methuen, 1967.

Imported Diseases SIR,-Tlhe recent articles on imported diseases are useful and point to some of the possible causes. But articles of this kind, designed for the general reader, must take especial care to inform and not to misinform. I must therefore take issue with Dr. A. M. Geddes (23 November, p. 454) on several points. A paragraph is devoted to Lassa fever. This is far from common, even in Africa, and few in Britain have seen even a single case of this highly infectious, distressing, and often fatal disease. The same amount of space is given to dengue fever, but no mention at all is made of the multitude of other viruses transmitted by mosquitoes,

Medical Nemesis SIR,-The gist of your leading article on Ivan Illich's Medical Nemesis' (7 December, p. 548) is that, while clearly much is wrong with medicine, there is nothing that doctors and other citizens cannot set to rights, that Illich is a somewhat wild man, if interesting, and that one cannot put the clock back. Of the three reviewers of his book (7 December, p. 573) one, Dr. A. Paton, gracefully accepts almost the whole Illichian thesis and two reject much of it. Professor G. Discombe makes four chief points. First, that Illich is often obscure; agreed. Second, that he is talking mostly about American medicine, to which the right answer is that increasingly American medicine is the kind that dominates the West and its outposts in underdeveloped countries. (Professor Discombe is, I am sure, aware that the U.S.A. is importing some 4000 doctors a year, many from underdeveloped countries, and at a time when the American male's expectation of life at birth is falling). Third, he seems to think that Illich would disapprove of the removal by means of the products of Western medical technology of "the shackles of ignorance, of disease, and of starvation from which the third world is trying to escape." In fact, I think, Illich would disapprove only if the price of such removal were to be a take-over of the indigenous culture by Western technology. After all, it is Professor Discombe, not Itllich, who says, "In an African town or village most people seem to be fairly happy and contented. But appearance is no guide to the load of sickness"-to which Illich would add that if he had to choose between destroying the load of sickness and perpetuating that of happiness he would choose the latter. He has no fear of the barefoot-doctor approach (or of alternative technology generally), only of its practitioners learning from doctors to professionalize themselves by means of a College of Barefoot Doctoring. Fourth, Professor Discombe thinks Illich an enthusiastic romantic-that is, that Illich is not a realist. Professor P. Rhodes, the third reviewer,

11 JANUARY 1975

adds various points-for instance, that "many would reject the thesis that pain, sickness, and death are to be welcomed." If what is meant is all pain, sickness, and death, then Illich would be one of the many. He says (Medical Nemesis, p. 121), "Deprofessionalization does not mean the abolition of modern medicine . . . [or] disregard for the special needs which people manifest at special moments in their lives: when they are born, break a leg, become crippled or face death." Professor Rhodes thinks "no man is an island," but believes that Illich wants man to be just that: Illich thinks industrial man is an island and that no man ever should be. Finally, Professor Rhodes too thinks Illich offers as a solution a retracing of our steps: "his solution is now not possible if it ever was." One common thread is clearly that Illich is not a realist (unlike doctors). As your reviewers and your leading article indicate, Illich regards medical nemesis as a part of a more generalized industrial nemesis, and it cannot be understood except in that larger context. As an unashamed romantic-in the Illichian mode-I think Illich is not a prophet of industrial (or medical) nemesis: like the rest of us, he is now a witness of its occurrence. Tihe clock is visibly going back. In what manner we should start going "forward" again-when that becomes possible-is perhaps the major question of our time. Illich supplies an answer to it.-I am, etc.,

JOHN S. BRADSHAW How Caple, Hereford

1 Illich, I., Medical Nemesis. London, Calder and Boyars, 1974.

Vitamin D Deficiency in Rheumatoid Arthritis SIR,-Drs. P. J. Maddison and P. A. Bacon (23 November, p. 433) omitted to give adequate details of the drug history in their rheumatoid arthritic patients who had clinical and biochemical evidence of osteomalacia. If they had been receiving longterm mild analgesics and anti-inflammatory drug therapy, I wonder if the authors had considered the role of a drug-induced disturbance of vitamin D metabolism in the aetiology of their patients' bone disease? There is now considerable evidence that long-term treatment with anticonvulsants can disturb the 'hepatic metabolism of this vitamin, probably by virtue of their powerful microsomal enzyme inducing properties.1-3 It is known that many mild analgesic drugs have a similar effect on liver enzymes,' and their chronic administration could therefore create a state of increased turnover of the vitamin in patients whose dietary intake and exposure to sunlight are already below average. Measurements of urinary D-glucaric acid excretion5 or plasma antipyrine or quinine half lives,67 which are indices of hepatic enzyme induction, would be interesting in these patients.-I am, etc., ALAN RICHENS Department of Clinical Pharmacology, St. Bartholomew's Hospital Medical College, London E.C.1 1 Richens, A., and Rowe, D. F. J., Bfitish Medical 7ournal, 1970, 4, 73. 2 Lancet, 1972, 2, 805.

Letter: Medical Nemesis.

94 of us spotted that he had fainted; we all mistook the faint for the onset of smooth anaesthesia, and but for a warning cried out by the technician...
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